Medical Tint Exemption Intake

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Medical Tint Exemption Intake

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Name *

First

Middle

Last

Phone *

Message and data rates may apply. One message per appointment.

Email *

Use a comma or press enter/return to add additional email addresses

Gender *

Date of Birth *

What is Your Florida Drivers License Number or Florida ID card Number? *

Registrant Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is your shipping address the same as your registrant address *

Yes
No

Shipping Address

Address Line 1

Address Line 2

City

State

Zip Code

What on ID

Do you agree to opt-in for text message notificaiton for: Updates from your healthcare provider, Shipping updates or Office staff notifications *

Yes
No

Medical Tint Exemption

What are you trying to use a medical tint exemption to help with? *

Lupus (with positive ANA titer)
Dermatomyositis (with positive ANA titer)
Albinism
Total or Facial Vitiligo
Xeroderma Pigmentosum
Other Autoimmune Diseases
Other medical condition which requires a limited exposure to light (ex.Photodermatitis/Cancers/Photophobia/Rosacea/Glaucoma etc.)
None of the above (Please note you will not be approved if selected)

How many vehicles are you looking to obtain an exemption for *

1 - $250.00
2 - $350.00
3 - $450.00

Please assure that if not approved you will be granted a full refund

Vehicle 1-Title Number (It is on your vehicle's registration)

Vehicle 1-Vin Number

Vehicle 1-Year

Vehicle 1-Make

Vehicle 2-Title Number (It is on your vehicle's registration)

Vehicle 2-Vin Number

Vehicle 2-Year

Vehicle 2-Make

Vehicle 3-Title Number (It is on your vehicle's registration)

Vehicle 3-Vin Number

Vehicle 3-Year

Vehicle 3-Make

Upload a picture of FL drivers license or ID card

Drag & Drop Files, Choose Files to Upload

Coupon

Total

$0.00

Authorize.Net *

Card Number

Expiration

/

Security Code

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

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(Call/Text- 7546008999)